1
Using Decision Support to Promote Value Based
Prescribing
Session 218, February 14, 2019
Adam Szerencsy, DO
Medical Director, Ambulatory Informatics
NYU Langone Health
2
Adam Szerencsy, DO
Has no real or apparent conflicts of interest to report.
Conflict of Interest
3
• Why are we doing this?
• Prioritizing medication classes to target
• Interventions
• Results
• Limitations
• Factors impacting success
Agenda
4
• Formulate a strategy for deploying decision support to influence
medication prescribing
• Evaluate what types of metrics should be used to measure
success
• Identify what factors contribute to provider acceptance of lower
cost, therapeutic equivalent medications
• Define external processes that may limit the effectiveness of
clinical decision support interventions
• Recognize barriers that may impact provider and patient adoption
and limit cost savings
Learning Objectives
5
• Value based payment programs continue to expand
• Healthcare organizations are consolidating to achieve
efficiencies
• Healthcare technology is critical to measure and improve
care
Background
6
• Over 400,000 attributed lives
• 2 billion in annual healthcare expenditures
• 3500 providers
• Approx. 75% of providers using our enterprise-wide EHR
• Value based arrangements with all major commercial and
government funded insurers
& NYU Langone IPA
7
& NYU Langone IPA
Cost
Saving
Patient
Satisfaction
Quality
• Bundled Payment
• Out of Network Spend
• Readmissions
• Reducing prescription
drug costs
• Screening and Prevention
• Chronic Disease Management
• Appropriate Use
• HCAHPS
• CGCAHPS
Value Based Medicine
8
Can we use clinical decision support to guide
clinicians to prescribe lower cost medications?
9
• High per member per month (PMPM) med spend
• Alignment across plan formularies
• Little risk that a medication change will impact care
• Significant cost differential between high cost medication and
alternative
• Strong evidence that therapeutic alternatives have similar efficacy
• Clinical leadership willing to support the initiative
Prioritizing Therapeutic Classes to
Target
10
*ULCER DRUGS/ANTISPASMODICS $2.02 17 351.3 $69 89.5%
*TETRACYCLINES $0.84 28 96 $105 92.5%
11
Biguanides
Glumetza
Fortamet
Metformin MOD
Tetracyclines
Oracea
Doryx
Morgidox
Monodox
Acticlate
Solodyn
PPIs
Nexium
Dexliant
Aciphex
Vimovo
(PPI/Naproxen)
Classes Individual Drugs
Wholesale
acquisition costs
(WAC)
Average manufacturer
price (AMP)
Estimated acquisition
cost (EAC)
Federal
Upper limit
(FUL)
Usual and
customary
(U&C)
Maximum
allowable cost
(MAC)
Drug Pricing
Alphabet Soup
13
Disclaimer: A representative AWP (Average Wholesale Price) price or price range is provided as reference
price only...The pricing data should be used for benchmarking purposes only, and as such should not be
used alone to set or adjudicate any prices for reimbursement or purchasing functions or considered to be an
exact price for a single product and/or manufacturer.
Source: Lexicomp
Source: Goodrx.com
Source: Goodrx.com
16
Therapeutic
Class
High Cost
Agent
Average
Wholesale
Price (AWP)*
Preferred
Alternative
Lowest
Retail
Price/Month*
Price
Differential/
Month
Biguanide
Fortamet
(Metformin ER)
$1260
Metformin ER
$18
$1242
Biguanide
Glumetza
(Metformin ER)
$3300
Metformin ER
$18
$3282
Biguanide
Metformin ER
MOD
$3600
Metformin ER
$18
$3582
*Source: Lexicomp
Therapeutic
Class
High Cost Agent
Average
Wholesale
Price (AWP)*
Preferred
Alternative
Lowest Retail
Price/Month*
Price
Differential
/Month
Tetracycline
Acticlate/Doryx
(Doxycycline Hyclate)
$953/$1315
Doxycycline
Hyclate
$18
$935/$1297
Tetracycline
Oracea/Monodox
(Doxycycline
Monohydrate)
$609/$394
Doxycycline
Monohydrate
$13
$596/$381
Tetracycline
Solodyn
(Minocycline)
$1219
Minocycline
$20
$1999
Tetracycline
Morgidox Kit
(Doxycycline Hyclate)
$550
Doxycycline
Hyclate
$18
$532
*Source: Lexicomp
Therapeutic
Class
High Cost Agent
Average
Wholesale Price
(AWP)*
Preferred
Alternative
Lowest Retail
Price/Month*
Price
Differential/
Month
PPI
Dexilant
(Dexlansoprazole)
$310
Omeprazole
Lansoprazole
Pantoprazole
$11
$18
$13
~$295
PPI
Nexium
(Esomeprazole)
$288
Omeprazole
Lansoprazole
Pantoprazole
$11
$18
$13
~$273
PPI
Aciphex
Rabeprazole
$529
Omeprazole
Lansoprazole
Pantoprazole
$11
$18
$13
~$514
PPI
Combination
Vimovo
Naproxen
-
Esomeprazole
$2473
Omeprazole
Lansoprazole
Pantoprazole
(+ Naproxen)
$11
$18
$13
($8)
~$2450
*Source: Lexicomp
19
Interventions
Preference List Modifications
Modified release
formulations ($$$$)
Standard extended
release formulation ($)
© 2019 Epic Systems Corporation. Used with permission.
20
Removed high cost agents from provider
and facility preference lists
Interventions
Preference List Modifications
© 2019 Epic Systems Corporation. Used with permission.
21
…and substituted them with lower cost alternatives.
Interventions
Preference List Modifications
© 2019 Epic Systems Corporation. Used with permission.
22
Interventions
Alternative Alerts
Design Principles
1. Substitute same medication whenever possible
2. Maintain similar dose and frequency
3. Simple message
4. Provide a reference for additional information
5. Mechanism for feedback
Interruptive messages recommending
lower cost alternatives to providers
23
High Cost Medication
Doryx 100 mg tablets
(Doxycycline Hyclate)
Solodyn 45 mg daily tabs
(Minocycline)
Fortamet 500 mg daily
(Metformin ER)
Fortamet 1000 mg daily
(Metformin ER)
Dexilant 30 mg daily
(Dexlansoprazole)
Vimovo 500-20 mg daily
(Naproxen-Esomeprazole)
Doxycycline Hyclate 100 mg capsules
Minocylcine 50 mg capsules
Metformin ER 500 mg daily
Metformin ER 1000 mg daily
Lansoprazole 15 mg daily
Pantoprazole 20 mg daily
Lansoprazole 30 mg daily
Pantoprazole 40 mg daily
(No Naproxen)
Interventions
Alternative Alert Mapping
Lower Cost Alternative
Metformin ER 500 mg daily
Metformin ER 750 mg daily
25
Interventions
Alternative Alerts
© 2019 Epic Systems Corporation. Used with permission.
26
• Approval at CIN Clinical Practice Committee
• Support from clinical chiefs within therapeutic areas
• Presentations at various committee meetings
• EHR end-user communication and newsletter announcements
Interventions
Socialization and Education
27
Results
Metformin
16.8%
18.5%
32.9%
9.4%
0%
5%
10%
15%
20%
25%
30%
35%
Overall Primary Care Endocrine Other Specialties
Acceptance Rate
Provider Specialty
Metformin Alternative Acceptance Rate
(n=1437)
28
Results
Metformin
12.8%
21.3%
0.0%
5.0%
10.0%
15.0%
20.0%
25.0%
Metformin 500 mg /750 mg ER -> Glumetza
1000 mg ER
Metformin 500 mg ER ->
Glumetza 500 mg ER
Metformin Acceptance Rate by Dose/Formulation
29
Results
Tetracyclines
16.5%
11.9%
43.4%
17.1%
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
Overall Derm Primary Care Other Specialties
Acceptance Rate
Provider Specialty
Tetracylines Alternative Acceptance Rate
(n=783)
30
Results
Tetracyclines
1.7%
68.8%
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
Doxycycline 20 mg - >
Oracea 40 mg
Doxy 100 mg caps - >
Adoxa 100 mg tabs
Alternative Acceptance Rate by
Dose/Formulation
31
Results
PPIs
10.1%
10.3%
10.4%
9.8%
0%
2%
4%
6%
8%
10%
12%
14%
16%
18%
20%
Overall Primary Care GI Other Specialties
Acceptance
Rate
Provider Specialty
PPI Alternative Acceptance Rate
(n=12,488)
32
Results
PPIs
30.8%
10.6%
0.6%
0.0%
5.0%
10.0%
15.0%
20.0%
25.0%
30.0%
35.0%
Omeprazole 20 mg ->
Esomeprazole 20 mg
Pantoprazole 40 mg ->
Dexlanzoprazole 60 mg
Omeprazole 20 mg ->
Vimovo (Naproxen/Esomeprazole)
Alternative Acceptance Rate by
Dose/Formulation
33
Results
Alternative
medications not
covered
6%
Dosing regimen not
appropriate
4%
Other (Comments)
14%
Patient preference
55%
Prior failure/intolerance of
alternative medication
21%
REASONS FOR CONTINUING
ORIGINAL MEDICATION
Dosing differences
Unwilling to change/
Change not necessary
Convenience
34
Results
Summary Over Time
0.0%
2.0%
4.0%
6.0%
8.0%
10.0%
12.0%
14.0%
16.0%
18.0%
Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18
Acceptance Rate
Acceptance Rate By Month
Results
Payer Data 2017 vs 2018
Baseline Period: 01/01/2017 - 12/31/2017; Current Period: 01/01/2018 - 09/30/2018; Claims Paid Through 09/30/2018
Baseline Current $ Trend % Trend Baseline Current % Trend Baseline Current % Trend Baseline Current
*Biguanides** $2.37 $1.78 -$0.59 -24.8% 245.4 244.9 -0.2% $116 $87 -24.7% 97.9% 98.5%
*Tetracyclines* $0.84 $0.59 -$0.25 -30.1% 96.0 88.0 -8.4% $105 $80 -23.7% 92.5% 95.0%
*Proton Pump Inhibitors** $1.49 $1.19 -$0.31 -20.5% 289.0 267.3 -7.5% $62 $53 -14.0% 88.6% 90.5%
Naproxen-Esomeprazole $0.31 $0.53 $0.22 71.3% 1.8 2.7 52.9% $2,083 $2,334 12.1% 0.0% 0.0%
PMPM Paid
Scripts/1,000
Unit Cost
% Generic
Decrease of
$0.93 PMPM
Results
Payer Data
Source: Anthem Commercial Monthly
-$0.77
-$0.23
$0.14
$0.15
-$0.71
-$1.00
-$0.80
-$0.60
-$0.40
-$0.20
$0.00
$0.20
$0.40
$0.60
$0.80
$1.00
1
PMPM Net Change
Net Change in PMPM Cost
2017 vs Jan-Jun 2018
(therapeutic classes combined)
Overall Net
Change PMPM
High Cost
Meds
Low Cost
Meds
Unit Cost:
High Cost Meds
Unit Cost:
Low Cost Meds
=
37
Limitations
• Disparate claims data from payers and member
roster changes make it challenging to calculate
total savings and definitively attribute them to our
interventions
• Inability to intervene for ‘DAW’ brand medications
• Not all providers using enterprise-wide EHR
• Inability to filter alerts for just our attributed
patients
38
Looking Ahead
© 2019 Epic Systems Corporation. Used with permission.
39
External Influencers
Prescriber
Patient
Efficacy
Better adherence
Once daily dosing
Combined meds
Prepackaged kits
Drug delivery mechanisms
Rx plan design
Formularies
Tiered Co-payments
Cost
Convenience
EHR
Prescription Drug
Market
December 21, 2017
Cost
Convenience
Warehouse Store
Sig: 0.65 oz po daily x 28 days
Disp: 18.2 oz
$5.99/12 oz
$12.99/18 oz
- $4.00 Rebate
$8.99/18 oz
$9.00/18 oz
Consumer
December 21, 2017
Cost
Convenience
Warehouse Store
Morgidox® Kit
100 mg capsules (#30)
+ Acuwash® cleanser
$549.04
$16.76
Prescriber
Patient
EHR
Source: Goodrx.com
December 21, 2017
Cost
Convenience
Warehouse Store
Morgidox® Kit
100 mg capsules (#30)
+ Acuwash® cleanser
$549.04
$16.36
Prescriber
Patient
EHR
~ $5 - $15
Co-payment
~ $30 - $50
Co-payment
Profits
Missed savings
opportunity
44
45
Provider Influencers
• Patient preference
• Status quo bias
• Pharmaceutical drug
promotion
• Health system education
• EHR
• Provider incentives
Favoring High Cost Meds
Favoring Lower Cost Meds
VS
46
Conclusions
• CDS interventions for promoting lower cost alternative
medications are effective
• Alternative medications with same dose/frequency correlate with
higher rates of alternative acceptance
• Patient preference greatly impacts acceptance rates - ease of
dosing regimen
• Many external factors, misaligned incentives and complex
relationships within the prescription drug market pose significant
challenges to achieving maximum benefit
